How many owners, officers, partners, and employees and independent contractors performing professional services?

Current Professional Liability Insurer:

Limits of insurance under current policy:

Revenues / Premium Volume:

Last 12 Months

Estimated Next 12 Months

Revenues (including fees)

Gross Written Premium

Do you provide, have you provided, or do you intend to provide any services other than those as an Insurance Agent/Broker (including but not limited to Financial Planning, Real Estate, Third Party Administration, Claims Adjusting, Investment/ Securities Advising, Actuarial, Legal, Tax Advising, Risk Management/Loss Control, Title/Escrow/Abstract, Vehicle Registration, Immigration Integration)?

Yes
No

Do you place any of the following lines of insurance:

Life, Accident & Health:

Yes
No

Property & Casualty:

Yes
No

Mutual Funds, Pensions, 401K Plans, Stocks/Bonds:

Yes
No

What percentage of the Life, Accident & Health written business is from the following:

Credit Life:

%

Life / Term Life:

%

Universal / Whole Life:

%

Variable Life:

%

Accident-AD&D:

%

Dental:

%

Long Term Care:

%

Fully Insured Health:

%

Self-Insured Health / Stop Loss:

%

Viaticals / Life Settlement:

%

METS / MEWAS:

%

Fixed Annuities / Indexed Annuities:

%

Variable Annuities:

%

Other:

%

Total Life, Accident & Health:

%

What percentage of the Property & Casualty written business is from the following:

Personal Auto/Motorcycle:

%

Commercial Trucking:

%

Personal Homeowners/Mobile Homes/ RVS/Dwelling:

%

Workers Comp:

%

Personal Wind/Flood/Earthquake:

%

Commercial Inland Marine:

%

Personal Umbrella:

%

Aviation:

%

Personal Non-Standard:

%

Bonds / Surety:

%

Personal Watercraft:

%

Crop:

%

Personal Inland Marine:

%

Livestock/Equine:

%

Boiler & Machinery:

%

Commercial Flood/Hail/Wind:

%

Commercial CMP/Package/BOP/CGL:

%

Wet/Ocean Marine:

%

Commercial Umbrella:

%

Professional Liability/Med Mal/D&O/EPLI:

%

Commercial Auto*:

%

Products Liability:

%

(*Excluding Trucking Related Placements)

Other:

%

Total Property & Casualty:

%

Claims Information:

Have you had any claims reported or closed in the past 5 years or do you have any open claims?

Yes
No

Have you ever had a claim in excess of $100,000?

Yes
No

Eligibility Questions:

Do you own or manage any risk assumption entities, including but not limited to, insurers, captives, risk retention groups, benefit plans or reinsurers; or own, manage or control any insurance clusters?

Yes
No

Do you have any non-exclusive independent contractors?

Yes
No

Do you require them to carry their own professional liability coverage?

Yes
No

Have you placed business, now or in the past, or do you plan in the future to place business as any of the following: Wholesaler, Managing General Agent/Underwriter, Reinsurance Intermediary, Surplus Lines Broker, or Program Administrator?

Yes
No

Have you ever placed coverage or been involved in insurance related services for any of the following:

Do you ever place business with carriers that have an A.M Best Rating below B+, that have a Demotech Rating below A, or that are currently not rated?

Yes
No

Have you had any agency contracts cancelled by an insurance carrier or underwriting company for reasons other than lack of productions?

Yes
No

Do you have offices in more than one state?

Yes
No

During the past 5 years has your name been changed, or has any business/firm been acquired, merged into, consolidated or sold off by/from the original firm?

Yes
No

Is your firm controlled, owned (in whole or in part), affiliated with, or associated with any other firm, corporation, company or entity, including but not limited to a Bank, Savings and Loan, or Credit Union?

Ever been subject to an investigation or inquiry by a state regulatory agency, an administrative agency and/or an insurance department, or disciplinary investigation or proceeding in any way, whether related to this coverage or not?

Yes
No

Ever been convicted for an act committed in violation of any law or ordinance other than traffic offenses?

Yes
No

Ever had a license revoked, suspended, or been fined by a state regulatory department or agency, whether related to this coverage or not?

Yes
No

Has any policy or application for professional liability insurance on your firmís behalf, its predecessor(s) in business, or any of its present or former owners, partners, officers, directors, employees or independent contractors ever been declined, cancelled or renewal refused within the last five years, except for carrier exit from the market?

Yes
No

Have you ever had a policy cancelled or non-renewed by Admiral Insurance Group, including for non-payment of premium?

Yes
No

After inquiry, are you, any predecessors in business, or any other person or firm for whom coverage is requested aware of any act, error, omission or circumstance which may possibly result in a claim being made against them, or has any claim or suit related to professional services been made against you that has not been reported to a prior carrier?

Yes
No

In the past 5 years, have you ever had a gap in professional liability coverage?

Yes
No

In the past five years have you, a related entity, subsidiary, or predecessor entity filed for bankruptcy or have plans to file bankruptcy?

Yes
No

COVERAGE DETAILS

Policy Limit

Deductible

Do you have an existing and in-force Insurance Agentís Professional Liability Policy and require Prior Acts Coverage?

Existing In-Force Policy?

Yes
No

Existing / In-Force Policy with a Retroactive Date

By selecting this option, you warrant that you have an expiring and in-force Insurance Agents Professional Liability policy with the same retroactive date selected below.

Yes
No

Expiration Date:

Retroactive Date:

Existing / In-Force Policy with Full Prior Acts

By selecting this option, you warrant that you have an expiring and in-force Insurance Agents Professional Liability policy that provides for Full Prior Acts coverage.

Yes
No

Expiration Date:

I/We declare that I/we have reviewed this Application for accuracy before signing it, that the above statements and representations are true and correct, and that no facts have been suppressed or misstated. I/We understand that this is an application for insurance only and that the completion and submission of this Application does not bind the Company to sell nor the applicant to purchase this insurance. I/We nevertheless acknowledge that any contract of insurance issued by the Company in response to this Application will be in full reliance upon the statements and representations made in this Application. I/We understand that any contract of insurance issued by the Company in response to this Application will be issued on a claims made form.

Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance, or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any material fact, commits a fraudulent insurance act, which is a crime and may also be subject to civil penalty.

I/We hereby declare that the above statements and particulars are true and I/we agree that this Application shall be the basis for any contract of insurance issued by the Company in response to it.

APPLICANT CERTIFICATION

By placing the initials of the applicant (Principal, Partner, or Officer) in the box below, the applicant acknowledges acceptance of the above, and understands that the initials carry the effect of a signature.

Initials:

Date:

Name of Applicant:

Title:

I have read and understand the APPLICANT CERTIFICATION section above(please check box before submitting)